Basic Information:
Name:

Age: 56 Sex: Male Ethnicity: Taiwan Occupation: bakery maker Marriage status: Married Admission Date: Sep. 11, 2010
Source and reliability of information: Patient himself, reliable
Chief Complaint: Chest pain for 5 days
Present Ilness:
This 56-y/o male, diabetic patient was admitted on Feb. 2nd due to mild left chest pain since 5 days ago. He was well before until the chest pain developed.
The chest pain was sharp in nature, located in the left lower chest area, persisted for whole day, and aggravated during deep inspiration. He cannot recall the onset of pain, as it appeared insidiously. At the same time, fever developed during the recent 2 days.
The fever is intermittent in nature and is evident at afternoon. No chillness was observed.
The pain was not radiated to jaw or left shoulder area. No diaphoresis was noted.
There was no tearing chest pain or hemoptysis. No recent chest trauma history and no purulent sputum were noted. He did not notice any skin rash over his chest.
He went to our ER this morning, and a CXR showed left pleural effusion. A thoracentesis revealed the effusion as an exudate with a pH lower than 7.2, a LDH higher than 1000. He was admitted for further management after a chest tube insertion.
Past history: Appendectomy 30 years ago
Diabetes mellitus for 15 years
Left leg cellulitis 2 years ago
Medical history: Glibenclamide 1# bid, Glucophage 1 tid for sugar control
Allergy history: NKDA
Social history: smoking (-), drinking: Beer about 2 cans a day for 20 years
Travel history: no recent travel within 6 months.
Family history:

Review of System:
General
□ Weight loss or gain
□ Fatigue
■ Fever or chills
Skin
□ Rashes
□ Lumps
□ Itching
Head
□ Headache
Ears
□ Decreased hearing
□ Ringing in ears (tinnitus)
Eyes
□ Vision
□ Glasses or contacts
□ Pain
□ Redness
Nose
□ Stuffiness
□ Discharge
□ Itching
Throat
□ Teeth
□ Gums
□ Bleeding
□ Weakness
□ Trouble sleeping
□ Dryness
□ Color changes
□ Hair and nail changes
□ Head injury
□ Earache
□ Drainage
□ Blurry or double vision
□ Flashing lights
□ Glaucoma
□ Cataracts
□ Hay fever
□ Nosebleeds
□ Sinus pain
□ Dentures
□ Sore tongue
□ Dry mouth

□ Sore throat
□ Hoarseness
□ Thrush
Neck
□ Lumps
□ Swollen glands
Breasts
□ Lumps
□ Pain
□ Discharge
Respiratory
□ Cough (dry or wet, productive)
□ Sputum (color and amount)
□ Coughing up blood (hemoptysis)
Cardiovascular
□ Chest pain or discomfort
□ Tightness
□ Palpitations
Gastrointestinal
□ Swallowing difficulties
□ Heartburn
■ Change in appetite
□ Nausea
□ Change in bowel habits
Urinary
□ Frequency
□ Urgency
□ Burning or pain
Genital
Male-
□ Pain with sex
□ Hernia
□ Penile discharge
□ Sores
Female-
□ Pain with sex
□ Vaginal dryness
□ Hot flashes
□ Non-healing sores
□ Last dental exam
□ Pain
□ Stiffness
□ Self-exams
□ Breast-feeding
■ Shortness of breath (slight dyspnea)
□ Wheezing
■ Painful breathing
□ Shortness of breath with activity
(exertion dyspnea)
□ Difficulty
□ Rectal bleeding
□ Constipation
□ Diarrhea
□Yellow eyes or skin (jaundice)
□ Blood in urine (hematuria)
□ Incontinence
□ Change in urinary strength
□ Masses or pain
□ Erectile dysfunction
□ STD’s
□ Vaginal discharge
□ Itching or rash
□ STD’s

Vascular
□ Calf pain with walking (Claudication) □ Leg cramping
Musculoskeletal
□ Muscle or joint pain
□ Stiffness
□ Back pain
□ Redness of joints
□ Swelling of joints
□ Trauma
Neurologic
□ Dizziness
□ Fainting
□ Seizures
□ Weakness
Hematologic
□ Ease of bruising
■ Numbness (distal limbs)
□ Tingling
□ Tremor
□ Ease of bleeding
Endocrine
□ Head or cold intolerance
□ Sweating
□ Frequent urination (polyuria)
Psychiatric
□ Nervousness
□ Depression
Physical Examination:
Consciousness: clear
Weight 70 kg; Height 168 cm
□ Thirst (polydypsia)
□ Change in appetite (polyphagia)
□ Memory loss
□ Stress
BP 130/70 (Right) 122/ 66 (left); PR: 90 RR: 21 BT 39
Conj: not pale
Sclera: not icteric
Neck: supple, LAP (-)
Chest:Insepection: reduced expansion over left side with a well functioning chest tube; spider angioma (-), gynecomastia (-)
Palpation: no crepitus
Percussion: resonance
Auscultation: BS: decreased over the left lower lung,
Heart: Inspection: PMI 5th intercostal space, 2 cm medial to the left mid-clavicular line Palpation: no heave, no thrill
Percussion: no increase of dullness
Ausculation: RHB, no murmur, normal splitting of S1 and S2, S3 (-), S4 (-)
Abdomen: Inspection: globular

Palpation: soft, no organomegaly, pain (-), tenderness (-), rebound (-)
Percussion: tympanic, No shifting dullness
Auscultation: BS: normoactive
Limbs: warm, no edema, cyanosis (-), lateral weakness (-), palmar erythema (-)
Peripheral pulse: symmetric and active
DRE: external hemorrhoids only
Laboratory data:
Biochemical test: sugar AC 140 mg/dL, AST 84, ALT 34, Total bilirubin 0.3, Cr 1.0,
LDH 132
CBC: WBC 12,000, Hb 12, Plt 240K,
Pleural effusion: pus like, LDH 1200, pH 7.1, WBC 1200 (70% of PMN)
2010-9-11
CXR showed meniscus sign, indicates the presence of left pleural effusion.
Problem List:
1.
Left pleural effusion, suspect Empyema
2.
DM type II with neuropathy
3.
Alcoholic liver disease
Assessment and Plan:
Problem 1: Left pleural effusion, suspect empyema

Assessment:
Infection should be first considered in diabetic patients (immunocompromised) with fever. The exudative character of left side pleural effusion plus leukocytosis indicates the infection foci of left pleural cavity. The pus nature, low pH and high LDH of pleural effusion diagnoses the presence of empyema. The usual cause of left side pleural effusion includes TB pleuritis and malignant pleural effusion and should be ruled out further.
Plan
Diagnostic: Record drainage amount, CBD D/C, CxR, Chest CT if necessary, pleural effusion cytology, AFS, TB PCR
Therapeutic: Cefoxitin 1gm iv Q6h, keep chest tube drainage, and consider to perform fibrinolytic therapy.
Education: care of chest tube and bottle
Problem 2: Diabestes Mellitus type II with neuropathy
Assessment:
Patient’s mother also has diabetes. Patient has had a history of diabetes mellitus for 15 years and is already using OHA to control the blood sugar. The numbness of distal limbs may indicate the diabetic neuropathy.
Plan:
Diagnostic: 4 parts blood sugar by finger stick, HbA1c, U/A
Therapeutic: Glibenclamide 1# bid, Glucophage 1 tid, using RI scale if sugar higher than 250 mg/dL
Education: Current BMI 24.8 = overweight should better to reduce it to 23, HbA1c should be kept below 7.0
Problem 3: Alcoholic liver disease
Assessment: This patient has beer drinking for 20 years. There is no sign of cirrhosis on physical examination. The ratio of serum AST and ALT are more than
2. The serum bilirubin level is normal. Alcoholic liver disease is considered.
Plan:
Diagnostic: GGT, Alk-p, abdominal sonography
Therapeutic: Thiamine 1 amp iv qd, Ativan (0.5) 1# hs
Education: Patient knows alcohol drinking is bad to health but he cannot sleep without alcohol. Besides, he feels his family relationship is not good that his wife and son do not care him much. He therefore, lacks of support and motivation to abstinent from alcohol. Further discussion with his family

and him is required and social worker will be consulted.

EBM
Question: Does fibrinolytic therapy for lobulated empyema add benefit to antimicromibial treatment?
Clinical bottom line:
Treatment with urokinase resulted in a significantly shorter hospital stay (7.4 v 9.5 days; ratio of geometric means 1.28, CI 1.16 to 1.41 p=0.027). A post hoc analysis showed that the use of small percutaneous drains was also associated with shorter hospital stay. Children treated with a combination of urokinase and a small drain had the shortest stay (6.0 days, CI 4.6 to 7.8).
Level of Evidence: Ia
Search terms :
P: Patients with empyema
I: Intrapleural urokinase
C: Anti-microbial alone
O: Hospital stay
References : Randomised trial of intrapleural urokinase in the treatment of childhood empyema Thorax 2002;57:343–347

Admission Order
Sep. 11, 2010
Admitted under the service of Dr. House
Diagnosis: Left pleural effusion, suspect empyema
Diabetes Mellitus type II with neuropathy
Alcoholic liver disease
Condition: Serious
Activity: Out of bed to chair
Vital sign: QID
Allergy: NKDA
Nursing: record chest drainage QD, CD chest tube wound QD, Finger stick for sugar
4 parts
Diet: DM diet 1800 cal
IV: N/S 500 ml + KCl 10 meq QD; D5W 500 ml + KCL 10 meq + RI 5U QD
Cefoxitin 1 gm IV Q6H
Thiamine(100mg) 1 amp IV QD
RI scale if sugar higher than 250 mg/dL
Medication: Glibenclamide(5mg) 1# bid,
Glucophage(500mg) 1 tid
Ativan (0.5mg) 1# hs
Laboratory: Check CBC, D/C, ALT, Cr, Na, K QW1, 4
CxR on next W1
Check GGT, Alk-p, HBsAg, HCV Ab, HbA1c st.
Arrange abdominal sonography
ECG, U/A

Progress Note
Sept. 12, 2010, 10:00 am
S: Pain on breath: better; pain of chest wound: still; less febrile
O: Consciousness: clear
BP 128/66; PR: 92; RR: 20; BT 38
Chest tube drainage 200 ml
Chest wound: slight erythema, no discharge
Sugar 224 in this morning
GGT 220; U/A: protein 60 g/L
Pleural effusion: GNB
Sonography: moderate fatty liver
A/P:
Problem 1: left empyema
A: condition is improving, on cefoxitin 2 nd
day
P: Pursue the result of bacterial culture
Keep on antibiotic use and chest tube drainage
Problem 2: DM
A: Blood sugar slightly high, Proteinuria due to diabetes
P: check 24 hr protein loss, add insulin injection to OHA if sugar rises further
Problem 3: alcoholic liver disease
A: alcoholic fatty liver, stable
P: Keep Thiamine iv qd and ativan (0.5mg) 1 hs
Progress Note
Sept. 13, 2010, 10:30 am
S: No fever, insomnia, slightly tremor of hands, mild sweating
O: Consciousness: clear
BP 144/68; PR: 108; RR: 24; BT 36
Chest tube drainage 180 ml
Chest wound: slight erythema, no discharge
Fine tremor of hands
Skin: wet
Na 136, K 4.4, Sugar AC 180
Bacterial culture: Klebsiella pneumonia
Problem 1: left empyema

A: Kp empyema, improving, on cefoxitin 3rd day
P: Keep on antibiotic use and chest tube drainage; follow up CXR tomorrow
Problem 3: alcoholic liver disease
A: Mild alcoholic withdraw syndrome after no alcohol drinking for 2 days
P: (N/S + KCL 10 meq) x II QD; (D5W + KCL 10 meq) x II QD; Thiamine (100) 1 amp IV QD; Ativan (0.5) 2# tid and 4# hs; Inderal (10) 1# tid; Adalat (10) 1# prn if
SBP > 140; consult Psychiatrist